Ambetter Pay for Performance (P4P) Program Available to PCPs

Date: 05/08/20

Ambetter from Superior HealthPlan is now offering a Pay-For-Performance (P4P) program for Primary Care Providers (PCP) designed to enhance quality of care through a focus on preventative and screening services. Providers accepting Ambetter are eligible to earn a performance bonus for achieving program measure targets. This program is an upside only program, meaning there is no financial risk to the provider if measure targets are not achieved. Also, there is no contractual obligation to participate in this program.

The P4P program pays out financial incentives to providers for engaging their members by closing care gaps. These care gaps are based on National Committee for Quality Assurance (NCQA) and Healthcare Effectiveness Data and Information Set (HEDIS) quality performance standard requirements.

See program details, required forms and contact information below:

• Within the program, each care gap measurement has its own incentive amount and is paid for each compliant member assigned to the provider once the target has been achieved for that specific measure.
• Incentives are paid out three times per year (Q2, Q3 and Q4) and credit will be received for all care gaps closed during the calendar year.
  • Incentive payouts are expected after Q2, Q3, Q4 with final reconciliation.
  • The PCP will receive credit for all gaps that are closed.
  • Funds will not be recouped if the provider terminates with the plan mid-year or no longer has assigned membership.

• Providers can access monthly reports on Superior’s Secure Provider Portal. These reports will include a scorecard on the measured service, including projected incentive amounts. They will also include detailed provider level scorecards and member-level quality gaps in care reports.
• The requirements for a payout are:
  • 75% of measure incentive amount for reaching Target 1
  • 100% of measure incentive amount for reaching Target 2

• There are currently 14 selected HEDIS measures focusing on PCP engagement, screening services and medication adherence which align with Quality Rating System (QRS) HEDIS measures. See measures below:
  • Member Engagement Ratio *
  • Medication Management Asthma (MMA) Total Age 5 to 64 75% Covered
  • Control High Blood Pressure (CBP) Total
  • Proportion Days Covered by Medication (PDC_QRS) ACE/ARB
  • Proportion Days Covered by Medication (PDC_QRS) Statins
  • Proportion Days Covered by Medication (PDC_QRS) Diabetes All Classes
  • Cervical Cancer (CCS)
  • Colorectal Cancer (COL)
  • Breast Cancer Screening (BCS)
  • QRS Comp Diabetes Care (CDC_QS) HbA1c Adequate Control (<8)
  • QRS Comp Diabetes Care (CDC_QS) Monitoring for Nephropathy
  • QRS Comp Diabetes Care (CDC_QS) Eye Exam
  • Antidepressant Medications (AMM) Effective Acute Phase Treatment    
  • Antidepressant Medications (AMM) Effective Continuation Phase Treatment

• HEDIS measures are evaluated using the NCQA HEDIS established guidelines. Each measure has two targets. Target 1 is set at the QRS 4-star target, and Target 2 is set at the QRS 5-star target.
• Providers can qualify and receive an incentive payment for one, multiple or all 14 of the HEDIS measures.

In order to participate in this program, providers must fill out the following forms and email them to the Clinical Engagement Team:

• W-9 Request for Taxpayer Identification Number and Certification (PDF)
• Automated Clearing House (ACH) Vendor Payment Authorization Form (PDF)
• Vendor Master Maintenance Form (PDF)

To submit the forms above or for questions on this program, please email Account Management at Statewide.AM@SuperiorHealthPlan.com.